McIntosh, Robert Dennis
Deceased
Robert Dennis McIntosh
Demographics
55y, male
Date of death
2013-05-29
Finding date
2015-06-12
Cause of death
gastrointestinal haemorrhage due to oesophageal varices due to hepatocellular carcinoma with portal vein thrombosis due to cirrhosis of the liver
AI-generated summary
Robert McIntosh, a 55-year-old prisoner with undiagnosed cirrhosis of the liver, hepatitis C, and hepatocellular carcinoma, died from gastrointestinal haemorrhage and oesophageal varices. While the coroner found that medical care provided was appropriate and death could not have been prevented, significant system gaps were identified in managing chronic liver disease in prison populations. The case highlights the need for improved screening, monitoring, and treatment protocols for prisoners with hepatitis C and cirrhosis—particularly given the very high prevalence in custodial settings. Key clinical lessons include: earlier specialist surveillance for known hepatitis C and cirrhosis with ultrasound screening for hepatocellular carcinoma; better detection of subtle liver dysfunction markers; adoption of newer non-invasive testing such as Fibroscan; and establishment of standardised protocols across all correctional health services. The coroner emphasised the importance of coordinated systemic improvements rather than individual clinical failures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- undiagnosed or inadequately monitored cirrhosis of the liver
- chronic hepatitis C infection
- hepatocellular carcinoma with vascular invasion
- portal vein thrombosis
- absence of regular ultrasound screening for hepatocellular carcinoma
- absence of routine monitoring for oesophageal varices in cirrhotic patients
- lack of specialised hepatitis C management protocols in correctional settings
- high prevalence of untreated hepatitis C in prison population
Coroner's recommendations
- The Queensland Government should convene a working party comprised of representatives from Queensland Health, Queensland Corrective Services, the West Moreton Hospital and Health Service, the Metro South Hospital and Health Service, AGCC and other correctional facilities to examine how the identification and management of patients with hepatitis and cirrhosis in correctional settings could be improved
- The working party should review the former 'Protocol for the management of viral hepatitis in offender health services' in consultation with appropriate experts, for distribution to all Hospital and Health Services
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